Addressing high-utilizers of virtual urgent care through an EHR clinical decision support nudge

Abstract

Virtual urgent care (VUC) has become an increasingly utilized resource for acute care delivery. Frequent utilization of VUC may reflect unmet longitudinal care needs and contribute to fragmented care. While high-utilizer patterns are well described in emergency departments, they have not been systematically characterized in telemedicine. We evaluated a clinical decision support (CDS) nudge designed to identify and address high utilizers of VUC at a large academic health system. An electronic health record alert triggered when patients met predefined high-utilizer criteria (>3 visits in 30 days, >12 in six months, or >20 in 12 months) and prompted providers to document a structured follow-up plan using a SmartPhrase. Among 473 eligible patients, 162 (34%) received the SmartPhrase. After adjustment for baseline utilization using negative binomial regression, SmartPhrase use was associated with a 22% relative reduction in VUC visits over the subsequent 30 days (incidence rate ratio 0.78, p = .03). Bootstrapped analyses confirmed a significant reduction in the SmartPhrase group (−1.47 visits; 95% CI [−2.19 to −0.62]), while no significant change occurred in the comparison group. These findings suggest that a low-cost, workflow-integrated CDS nudge may reduce short-term telehealth overutilization by prompting structured follow-up discussions and encouraging longitudinal care planning.

Plain language summary

Using an electronic health record alert to help frequent users of virtual urgent care

Virtual urgent care (VUC) allows patients to see a healthcare provider online for urgent concerns. It has become a common and convenient way to receive medical care. However, some patients use VUC repeatedly for ongoing issues that may be better managed through regular primary care. This repeated use can lead to fragmented care, higher healthcare costs, and unresolved health problems.

In our health system, we noticed that a small group of patients accounted for a large number of virtual urgent care (VUC) visits. To better support these patients, we created a simple electronic alert in the medical record. When a patient met certain “high-use” criteria, the system nudged the provider to discuss follow-up care and document a plan in the visit note.

We studied whether this nudge made a difference. Among patients whose providers used the follow-up discussion prompt, VUC visits decreased by about 22% over the next 30 days. In contrast, patients whose providers did not use the prompt did not experience a decrease in visits. This suggests that a brief, structured conversation about ongoing care may help reduce repeated urgent visits.

Importantly, this intervention was low-cost and easy to implement. Rather than limiting access to care, it encouraged providers and patients to think about longer-term solutions. As virtual care continues to expand, simple nudges like this may help ensure that patients receive the right care in the right setting.